Systemic Lupus Erythematosus Case Study

Author/s

Sara Gress, Kelly Mudlo, Micheal Rangel, and Shelby Wagoner from the Bellarmine University Physical Therapy Program's Pathophysiology of Complex Patient Problems Project.

Definition/Description

Lupus erythematosus, sometimes referred to as lupus, is a chronic inflammatory autoimmune disorder that appears in several forms; discoid lupus erythematosus (DLE), which affects only the skin, and systemic lupus erythematosus (SLE), which can affect any organ or system of the body. Other forms include drug-induced lupus, antiphospholipid antibody syndrome, and late-stage lupus.

Systemic lupus erythematosus belongs to the family of autoimmune rheumatic disorders that can be characterized by injury to skin, joints, kidneys, heart and blood-forming organs, nervous system, and mucous membranes. Discoid lupus is a limited-form of the disease confined to the skin presenting as coin-shaped lesions, which are raised and scaly. Discoid lupus rarely develops into systemic lupus. Systemic lupus is usually more severe than discoid lupus and can affect almost any organ or system of the body. For some people, only the skin and joints will be involved. In others, the joints, lungs, kidneys, blood, or other organs or tissues may be affected.

Background/Prevalence

The exact cause of SLE is unknown, although it appears to result from an immunoregulatory disturbance brought about by combination of genetic, hormonal, chemical, and environment factors. Some of the enviormental factors that may trigger the disease are infections (e.g., Epstein-Barr virus), antibiotics, and other medications, exposure to ultraviolet light, extreme physical and emotional stress, including pregnancy. Although there is a known genetic predisposition, no known gene is associated with SLE.

• Relatively rare disease which occurs in 15-124/100,000 of the population worldwide.
• Most common in persons between the ages of 15-40 years.
• Rarely occurs in the elderly population. 
• Women are affected 10-15x more often than men. 
• About 6-19% of lupus patients, the diagnosis was made after the fifth and sixth decades of the patients life.
• During the disease course, discoid rash lesion is significantly more common in men compared to females.
• The disease is 2-4x more frequent and severe in among nonwhite populations around the world and tends to be more severe in men, pediatric, and late-onset lupus.
• More prevalent in first-generation family history more often when compared to the general population.

Patient Characteristics

Patient demographics

• Patient is a 46 year old caucasian female who works full time as a secretary. She presented to the hospital with a six-month history of generalized weakness and significant weight loss of 40 lbs.

Current diagnosis

• Systemic Lupus Erythematosus, acute inflammatory arthritis of elbows and knees.

Co-morbidities

• Hypertension: unmanaged by medications due to financial constraints
• Obesity: BMI 28

Previous care or treatment

• This patient has been treated for past episodes of leukopenia on more than two occasions.

Examination

Subjective:

• Patient presented to the hospital with a six-month history of generalized weakness and significant weight loss of 40 lbs over the past 4 months. Over the past two weeks, she has been having progressing symptoms of worsening dyspnea. She has been unable to do yard work due to her fatigue and pain in her elbows and knees. She has had to take leave from work for several weeks due to her inability to type and sit for long periods of time.

Patient History and Systems Review:

• Patient has no history of smoking, drug, or alcohol use. She has had a history of leukopenia on several occasions, but this episode of symptoms seems to be the most exaggerated. She has not hospitalized for any other relevant conditions. Her goals are to return to work and to be able to perform household duties with less pain and fatigue.

Self Report Outcome Measure:

• Systemic Lupus Activity Measure-Revised (SLAM-R): 20/81

Physical Performance Measures: 

• 5 sit to stands in 30 seconds 

Objective :

• Blood pressure: 102/66 mm/Hg
• Heart Rate: 88 bpm
• Temperature: Normal
• Respiratory Rate: 24 breaths/min
• Oxygen saturation: 92%
• Lab results revealed anemia, leukopenia, elevated blood urea nitrogen, and elevated creatinine. Urinalysis showed trace proteinuria.
• Serological work-up: high anti-nuclear antibody, anti-double stranded DNA antibody, and anti-Smith antibody titers

Physical Examination

• Integumentary observation: Patient presented with mucosal pallor, showed no signs of cyanosis, digital clubbing, pitting edema, skin rash, or joint deformities.
• Palpation/percussion: Examination and palpation of patient’s distended abdomen was non-tender to palpation. Palpation of lymph nodes revealed rubbery axillary and inguinal lymphadenopathy.
• Respiratory system: Decreased breath sounds and dullness to percussion were noted on the left base.
• Cardiovascular and Neurological: Unremarkable
• ROM: Painful ROM in bilateral elbows and knees. All other joints WNL
• MMT: Generalized weakness
  
  

Summarization of Examination Findings

Working Diagnosis and Targeted Interventions

Intervention

• Phases of Interventions (e.g. protective phase, mobility phase, etc.)
• Dosage and Parameters
• Rationale for Progression
• Co-interventions if applicable (e.g. injection therapy, medications)

Outcomes

With physical therapy intervention, the patient was able to reach her goals. She has returned to work and is able to perform household duties in the absence of pain and with minimal fatigue. By discharge, the patient was in a remissive state with complete absence of pain in bilateral knees and elbows.

Self Report Outcome Measure:
• Systemic Lupus Activity Measure-Revised (SLAM-R): 50/81
Physical Performance Measures:
• 5 sit to stands in 13 seconds

The patient’s improvement on the SLAM-R indicates decreased disease activity and disease severity.
The patient’s improvement on the Five Times Sit to Stand Test indicates increased functional lower limb muscle strength.

Discussion

When treating a patient with Systemic Lupus Erythematosus, patient education is key. It is important to inform them that refraining from smoking and protecting their skin from the sun can drastically improve their disease severity. Photosensitivity occurs in 75% of individuals with SLE. Smoking drives hypertension common in SLE and interferes with the benefit of hydroxychloroquine (Plaquenil), an anti-malarial drug used to treat SLE. Educating the patient about continuing their exercise regimen after they are discharged from physical therapy treatment is beneficial. Regular exercise helps prevent fatigue and joint stiffness. Furthermore, regular, moderate physical activity can prevent the neuroendocrine and detrimental immunological effects of stress. This is particularly important for an individual with an autoimmune disorder.
During a stent of treatment, since the physical therapist will see the individual with SLE frequently, it is important to be a “physician extender” of sorts. Due to training in differential diagnosis, physical therapists are equipped with the knowledge to determine when a patient needs to be referred back to their primary care provider. Physical therapists should monitor any patient on corticosteroids or immunosuppressants for signs of infection. Avascular necrosis is a possibility in those on corticosteroids. The most common site is the femoral head. Another less probable site is the femoral condyle of the knee. If the patient exhibits insidious onset of unilateral hip or knee pain that is worse with ambulating but often present at rest with symptoms present over weeks to months, refer to primary care provider. Also, be aware of any changes in bone density and screen for the presence of developing osteoporosis before including any resistive exercise, muscle-energy techniques or self-mobilization techniques. This may be a side effect of years of steroidal anti-inflammatory medications. Long term steroid therapy has been linked to diabetes mellitus, hyperlipidemia, and obesity as well. Observe for any renal involvement. Signs may include weight gain, edema, or hypertension. If there are signs of cognitive decline, this is a reason for referral. Raynaud’s phenomenon may become present. If so, inform the patient of the importance of warming and protecting the hands and feet.
In conclusion, it is important to know the comorbidities of SLE in order to know when a referral is appropriate.

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